SBC0157W081620171342TXEQ0025 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning on or after 10/01/2017 HUMANA HEALTH PLAN OF TX, INC/HUMANA INSURANCE CO: TX NCR NPOS EHDHP Coverage for: Individual + Family Plan Type: NPOS-HDHP 16 DED/COINS OV,IP,OP, RX4 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.groupcertificate.humana.com or by calling 1-866-4ASSIST (427-7478). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment,, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-866-4ASSIST (427-7478) to request a copy. Important Questions Answers Why This Matters: What is the overall? Are there services covered before you meet your? Are there other s for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Network: $5,000 Individual / $10,000 family; Non-Network: $15,000 Individual / $30,000 family Doesn't apply to network preventive services. Coinsurance and copayments don't count toward the Network Providers: Yes. Preventive. Non-Network Providers: No. No For network providers $6,350 individual / $12,700 family; For non-network providers $19,050 individual / $38,100 family Premiums, Balance-billing charges, Health care this plan doesn't cover, Penalties, Non-network transplant, non-network prescription drugs, non-network specialty drugs Generally, you must pay all of the costs from providers up to the amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual until the total amount of expenses paid by all family members meets the overall family. This plan covers some items and services even if you haven't yet met the amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. You don't have to meet s for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don't count toward the out of pocket limit. S081617 1 of 7
Will you pay less if you use a network provider? Do you need a referral to see a specialist? Yes. See www.humana.com/directories or call 1-866-4ASSIST (427-7478) for a list of network providers No This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your has been met, if a applies. Common Medical Event If you visit a health care provider's office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care / screening / immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Network Provider (You will pay the least) No charge What You Will Pay Non-Network Provider (You will pay the most) None None Limitations, Exceptions, & Other Important Information You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Imaging: Cost share may vary based on where service is performed 2 of 7
Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.humana.com/2017- HDHP-Traditional Scenario 38 If you have outpatient surgery Services You May Need Level 1 - Lowest cost generic and brand-name drugs Level 2 - Higher cost generic and brand-name drugs Level 3 - Generic and brand-name drugs with higher cost than Level 2 Level 4 - Highest cost drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Network Provider (You will pay the least) $10 copay (Retail) $25 copay (Mail $30 copay (Retail) $75 copay (Mail $50 copay (Retail) $125 copay (Mail 25% coinsurance (Retail) 25% coinsurance (Mail What You Will Pay Non-Network Provider (You will pay the most), after network copay (Retail), after network copay (Mail, after network copay (Retail), after network copay (Mail, after network copay (Retail), after network copay (Mail, after network Coinsurance (Retail), after network Coinsurance (Mail None Limitations, Exceptions, & Other Important Information 30 day supply obtained, penalty will be 100% for certain prescription drugs (Retail) 90 day supply obtained, penalty will be 100% for certain prescription drugs (Mail Non-network cost sharing does not count toward the out-of-pocket limit. 3 of 7
Common Medical Event If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services If you are pregnant Services You May Need Emergency room care Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fees Outpatient services Inpatient services Network Provider (You will pay the least) What You Will Pay Non-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information None None Inpatient services: Office visits: Cost sharing does not apply for preventive services. Office visits No charge; does not apply Childbirth/delivery professional services: Depending on the type of services, a may apply. Childbirth/delivery facility services: Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound) Preauthorization may be required - if not Childbirth/delivery professional services Childbirth/delivery facility services. 4 of 7
What You Will Pay Common Medical Event Services You May Need Network Provider (You will pay the least) Non-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information If you need help recovering or have other special health needs Home health care Rehabilitation services Therapies: Manipulations and Therapies: 30 Physical Therapy, Occupational Therapy, Speech Therapy, Cognitive Therapy, Audiology Therapy visits per year includes manipulations & adjustments For non-network, 10 Physical Therapy, Occupational Therapy, Speech Therapy, Cognitive Therapy, Audiology Therapy visits per year includes manipulations & adjustments Habilitation services If your child needs dental or eye care Skilled nursing care Durable medical equipment Hospice services None Children's eye exam Not Covered Not Covered None Children's glasses Not Covered Not Covered None Children's dental check-up Not Covered Not Covered None 60 day limit per year for durable medical equipment $750 and over Excludes vehicle and home modifications,exercise and bathroom equipment 5 of 7
Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of other excluded services.) Acupuncture Cosmetic Surgery Non-Emergency Care, when traveling outside of the U.S Bariatric Surgery Dental Care (Adult) Private Duty Nursing Child Dental Check-Up Hearing Aids Routine eye care (Adult) Child Eye Exam Infertility Treatment Routine Foot Care Child Glasses Long Term Care Weight Loss Programs Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) Limitations may apply to these services as permitted by applicable law. These limitations are listed in your plan document. Chiropractic Care Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or http://www.dol.gov/ebsa/healthreform or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or http://www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.healthcare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Humana, Inc.: www.humana.com or 1-866-4ASSIST (427-7478). Department of Labor Employee Benefits Security Administration: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform Texas Department of Insurance, PO Box 149104, Austin, TX 78714-9104, Phone: 800-578-4677 or 800-252-3439, TDD: 512-322-4238, Website: http://www.tdi.texas.gov/index.html Does this plan provide Minimum Essential Coverage? Yes. If you don't have Minimum Essential Coverage for a month, you'll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al www.humana.com or by calling 1-866-4ASSIST (427-7478) To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 7
About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (s, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan's overall $5,000 Specialist copayment $0 Hospital (facility) coinsurance 0% Other coinsurance 0% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles $5,000 Copayments $30 Coinsurance $0 What isn't covered Limits or exclusions $0 The total Peg would pay is $5,030 Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) The plan's overall $5,000 Specialist copayment $0 Hospital (facility) coinsurance 0% Other coinsurance 0% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $3,600 Copayments $500 Coinsurance $0 What isn't covered Limits or exclusions $20 The total Joe would pay is $4,120 Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan's overall $5,000 Specialist copayment $0 Hospital (facility) coinsurance 0% Other coinsurance 0% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $1,900 Copayments $0 Coinsurance $0 What isn't covered Limits or exclusions $40 The total Mia would pay is $1,940 The plan would be responsible for the other costs of these EXAMPLE covered services. 7 of 7